Abstract

Background Previous research has found that African–Caribbean
and Black African patients are likely to come into contact with mental health
services via more negative routes, when compared with White patients. We
soughtto investigate pathways to mental health care and ethnicityin a sample
of patients with a first episode of psychosis drawn from two UK centres.

Method We included all White British, other White,
African–Caribbean and Black African patients with a first episode of
psychosis who made contact with psychiatric services over a 2-year period and
were living in defined areas. Clinical, socio-demographic and pathways to care
data were collected from patients, relatives and case notes.

Results Compared with White British patients, general practitioner
referral was less frequent for both African–Caribbean and Black African
patients and referral by a criminal justice agency was more common. With the
exception of criminal justice referrals for Black African patients, these
findings remained significant after adjusting for potential confounders.

Conclusions These findings suggest that factors are operating during
a first episode of psychosis to increase the risk that the pathway to care for
Black patients will involve non-health professionals.

Compared with White patients, African–Caribbean and Black African
patients in the UK are likely to access mental health care more often through
criminal justice agencies and less often through general practitioner referral
(Bhui et al, 2003).
However, as with compulsory admission, the reasons for this remain unclear,
primarily because of methodological limitations characterising much previous
research (Morgan et al,
2004). Few studies have investigated ethnicity and the pathway to
first contact with mental health services. Those that have suggest the pattern
observed in most general studies, i.e. low levels of general practitioner
referral and high levels of criminal justice referral, is not evident at
initial contact. For example, both Harrison et al
(1989) and Cole et al
(1995) found no ethnic
difference between general practice and criminal justice agency referrals at
first presentation. The previous studies, however, have been restricted in
their capacity to examine this thoroughly because of the small sample sizes
involved.

Using data from a large, multicentre epidemiological study of first-onset
psychosis, we sought to test the hypothesis that African–Caribbean and
Black African patients would come into contact with mental health services
less often through their general practitioner and more often through a
criminal justice agency, independent of potential confounders such as
socio-demographic characteristics and diagnosis.

METHOD

This research forms part of the Aetiology and Ethnicity in Schizophrenia
and Other Psychoses (ÆSOP) study, a population-based study of
first-episode psychosis. Details of the study and the methods used to collect
data relating to pathways to care have been set out in a companion paper
(Morgan et al, 2005,
this issue), and consequently we restrict ourselves here to emphasising or
noting additional relevant points regarding the methods used.

Data collection and study variables

For the purposes of this part of the investigation the same
socio-demographic variables were used as in the analysis of compulsory
admissions: ethnicity, gender, educational level, employment status, living
circumstances and relationship status. The two primary clinical variables used
in the analysis were duration of untreated psychosis, and diagnosis. For the
analysis, patients were grouped into three categories according to
ICD–10 diagnostic criteria (World
Health Organization, 1992): broad schizophrenia and other
psychoses (ICD–10 codes F20–29), manic psychosis (F30–31)
and depressive psychosis (F32–33). Data relating to the pathway to care
were derived from a slightly modified version of the Personal and Psychiatric
History Schedule (PPHS; World Health
Organization, 1996). For this study, data were collected that
focused on two key points on the route to care: the person who initiated
help-seeking, and the source of referral to mental health services. In
addition, the involvement of family and friends, criminal justice agencies
(police, courts, prisons) and general practitioners at any point on the route
to care was recorded.

Ethnicity

Patients assigned to one of the following four ethnic groups were included
in the analysis:

White British: all White patients with at least one parent born in the
UK;

African–Caribbean: all Black patients born in the Caribbean or born
in the UK with at least one parent of Caribbean origin;

Black African: all Black patients born in sub-Saharan Africa or born in the
UK with at least one parent of sub-Saharan African origin;

other White: all White patients with no parent born in the UK.

There was no patient of mixed Caribbean–African parentage in the
study, and patients of other ethnicities were excluded from the analysis. The
procedure followed for assigning ethnicity is set out in Morgan et al
(2005).

Analysis

Univariable analyses were conducted using chi-squared tests and odds ratios
with 95% confidence intervals, and multivariable analyses were conducted using
logistic regression. The multivariable analyses focused on two primary
outcomes: general practitioner referral and criminal justice agency referral.
For each outcome a logistic regression model was constructed using a forward
fitting procedure. Briefly, this involved first fitting a model that included
the primary outcome, exposure (ethnicity) and a variable for study centre, and
second, adding other variables crudely associated with the outcome (either
general practitioner referral or criminal justice referral) one by one,
starting with the strongest. If appropriate, interaction terms were also
fitted. For each new variable or interaction term fitted, a likelihood ratio
test was conducted by checking each nested model against the new potential
model. Variables and interaction terms were retained in the model if the
P value for the likelihood ratio test was <0.10. All analyses were
conducted using STATA version 8 (Stata,
2003).

RESULTS

A total of 462 patients were included in the univariable analyses. Data
relating to the two main outcomes of interest – general practitioner
referral and criminal justice agency referral – were not available for
three patients, and these were excluded from the multivariable analyses of
these outcomes. The small number of patients for whom other data were missing
were included and the missing values are noted in the relevant tables. Where
data were missing this was primarily due to absence of clear information in
case notes. There was no evidence that the proportion of missing values varied
systematically between key groups in the sample.

Pathways to care

There were notable differences between ethnic groups in pathways to mental
health care (Table 1). In
south-east London, only 26% of African–Caribbean and 21% of Black
African patients were referred to services by their general practitioner
compared with over 40% of patients from both White ethnic groups. The
proportions were remarkably similar in Nottingham, with 42% of White British
patients being referred by their general practitioner compared with 21% of
African–Caribbean patients. These differences are reflected in the
relative lack of general practitioner involvement at any point on the pathway
to care. Conversely, levels of criminal justice agency involvement in the
pathway to care were higher among African–Caribbean patients in both
centres, and among Black African patients in south-east London. Overall,
criminal justice agencies were involved in less than 20% of White British
patients’ contacts compared with over 35% of
African–Caribbeans’ and over 40% of Black Africans’
contacts. Although the difference between White British and
African–Caribbean patients in the Nottingham sample does not reach
statistical significance, the similarity to the south-east London data
suggests the same effect. Intriguingly, when police involvement in the pathway
to care is considered in terms of the person who initiated help-seeking,
African–Caribbean family and friends were more likely to have sought
help from the police than White British family and friends: White British
n=13 (13.3%) v. African–Caribbean n=11
(26.5%); χ2=3.46, d.f.=1, P=0.06.

There was no ethnic difference in either centre in the proportion of
patients accessing care through accident and emergency departments or (in
south-east London) the Maudsley Hospital emergency clinic. Overall, very few
patients accessed care through domiciliary visits. However, in Nottingham
there was a marked difference between the two main ethnic groups in the
proportions accessing care by this route: over 30% of African–Caribbean
patients accessed care through a domiciliary visit compared with less than 6%
of White British patients (χ2=17.85, d.f.=1,
P<0.01). Of the 17 domiciliary visits in Nottingham, the police
were involved in 6 (35.3%), which suggests that such visits were often crisis
referrals. With regard to patterns of help-seeking, African–Caribbean
patients in both south-east London and Nottingham were less likely to seek
help themselves (Table 1).
Conversely, for the Black African group in south-east London, levels of family
or friend involvement in help-seeking were low compared with the White British
group.

Taken together, these findings all point in the same general direction:
that is, they are suggestive of more negative routes to care for
African–Caribbean and Black African patients than for White British
patients. Focusing on source of referral, the question to be answered is why
Black patients access care less often through general practitioners and more
often through criminal justice agencies. The next stage of the analysis sought
to address this by controlling for a number of potential confounding factors
that might explain the association between ethnicity and these two sources of
referral. Data for south-east London and Nottingham were combined for the
multivariable analyses, and a variable for study site included in each model
to control for any effect of location or service setting.

General practitioner referral

Table 2 presents the
unadjusted odds ratios for general practitioner referral by each independent
variable. There was no evidence of effect modification between general
practitioner referral, ethnicity and any other variable. In addition to
ethnicity, seven variables were associated with an increase or decrease in the
odds of general practitioner referral at P<0.10. A logistic
regression model was fitted, as detailed above. Following this procedure, five
of the seven variables crudely associated with general practitioner referral
were selected for inclusion: male gender, living alone, diagnosis,
self-initiated help-seeking and family involvement in the pathway to care. The
final logistic regression model (Table
3) shows that, when adjusting for the other variables in the
model, the odds of general practitioner referral for both
African–Caribbean and Black African patients are less than half those
for White patients, with little attenuation of the unadjusted odds ratios.
This provides strong evidence that, compared with White British patients,
levels of general practitioner referral are lower for African–Caribbean
and Black African patients independent of diagnosis, living circumstances,
gender, and whether help was sought by the patient or with the involvement of
family and friends. Each of these other variables was also independently
associated with an increase or decrease in the odds of general practitioner
referral, suggesting that multiple factors influence who accesses care through
a general practitioner. There is no evidence of a difference in the odds of
such referral between the two study centres. It should be noted, moreover,
that 95% of patients in all ethnic groups were registered with a general
practitioner (total number registered 440).

Criminal justice agency referral

Table 4 presents the
unadjusted odds ratios for criminal justice agency referral by each
independent variable. At this point self-initiated help-seeking was not
considered, because (not surprisingly) no patient sought help directly from a
criminal justice agency. There was no evidence of effect modification between
criminal justice referral, ethnicity and any other variable. In addition to
ethnicity, three variables were associated with an increase or decrease in the
odds of criminal justice agency referral at P<0.10. A logistic
regression model was fitted, as detailed above. Following this procedure, all
variables crudely associated with criminal justice agency referral were
selected for inclusion: being unemployed, diagnosis and family involvement in
the pathway to care. The final logistic regression model is presented in
Table 5.

When adjusting for other variables in the model, there is some attenuation
of the odds ratios for criminal justice referral for both
African–Caribbean and Black African patients. The adjusted odds ratio
for African–Caribbean patients is 1.98 (P=0.036) compared with
an unadjusted odds ratio of 2.52 (P<0.001), which suggests some
confounding by diagnosis, unemployment and family involvement. However, even
after adjusting for these variables, there remains fairly strong evidence of
an association between African–Caribbean ethnicity and criminal justice
agency referral. The evidence for an independent association between Black
African ethnicity and criminal justice referral, after adjusting for the other
variables, is weaker, the adjusted odds ratio being 1.87 (P=0.115)
compared with the unadjusted odds ratio of 2.89 (P<0.001). It may
be that differences in diagnosis, levels of family involvement and
unemployment are sufficient to explain the excess of criminal justice agency
referrals in the Black African group. However, these do not fully explain the
excess for the African–Caribbean patients, which suggests that
additional factors might be at work which increase the odds of criminal
justice referral for this group. Of the other variables included in the final
model, lack of family involvement has the strongest relationship with criminal
justice referral, suggesting a key role for family and friends in facilitating
a route to care that does not necessitate intervention from criminal justice
services. As with general practitioner referrals, there was no evidence of
notable differences between the two study sites.

DISCUSSION

The key respects in which this study overcomes some of the methodological
limitations of previous research are its large sample size and the comparison
of two centres. It is these features of the study that have allowed the
determinants of source of referral at first contact with mental health
services to be considered in more detail than before.

Ethnicity and source of referral at first contact

Most previous research has suggested that African–Caribbean and Black
African patients are less likely to access care through a general practitioner
and more likely to access care through a criminal justice agency in the UK.
However, studies that have included data relating to source of referral at
first presentation have not found statistically significant ethnic differences
(Harrison et al, 1989;
Cole et al, 1995;
Burnett et al, 1999).
Our study, therefore, is the first to unequivocally find marked ethnic
differences in the pathway to care at first presentation.

In both south-east London and Nottingham, African–Caribbean patients
were significantly less likely to access care through a general practitioner
than were White British patients: in both centres, less than 30% of
African–Caribbean patients accessed care in this way. In south-east
London a similar pattern was evident for Black African patients, with only 21%
being referred to services by a general practitioner. These proportions of
general practitioner referral are at the low end of the spectrum reported in
previous research. Indeed, although some studies have reported similar
proportions to those presented here (e.g.
Harrison et al, 1984),
albeit in very different patient samples, others have reported higher
proportions for African–Caribbean patients. Burnett et al
(1999), for example, in a study
in a similar area of south-east London to that used for our study, reported
that 37% of African–Caribbean patients had been referred by a general
practitioner compared with 50% of White patients. The study by Harrison et
al (1989) of first-onset
psychosis in Nottingham reported a much higher level: 60% for
African–Caribbean patients compared with 76% for a general population
sample. In both the latter studies, proportions of general practitioner
referral were lower for African–Caribbean patients than for Whites,
although not significantly so. The fact that these differences were not
statistically significant may simply be a function of small sample sizes.

In south-east London over 30% of referrals for African–Caribbean and
Black African patients were made through a criminal justice agency, usually
the police. In both centres, criminal justice agency involvement in the
pathway to care was over 35% among African–Caribbean and Black African
patients. These are similar to previously reported findings. Burnett et
al (1999), for example,
found that 34% of African–Caribbean patients accessed care through a
criminal justice agency compared with 21% of White patients, although the
small numbers involved again meant this difference was not statistically
significant.

The other major difference between ethnic groups in terms of the pathway to
care was in the person who initiated, and who was involved in, help-seeking
from professional health services. In both south-east London and Nottingham,
levels of self-initiated help-seeking were lower for African–Caribbean
patients compared with White British patients, although levels of family
involvement were similar. In contrast, in south-east London levels of
self-initiated help-seeking were similar for Black African and White British
patients, although levels of family involvement were lower for Black African
patients. Few studies have considered these features of the pathway to care
and so it is difficult to draw comparisons with previous research. Burnett
et al (1999) did
distinguish between those who sought help from a general practitioner
themselves and those whose family sought help from a general practitioner on
their behalf, and found that self-initiated help-seeking was significantly
lower among African–Caribbean patients compared with White patients.

Together, these findings point to marked differences in the pathway to care
between different ethnic groups at first presentation. This suggests that
there are processes operating prior to first presentation that increase the
risk of more negative pathways to care for African–Caribbean and Black
African patients.

Explaining the differences

Clinical disturbance

In one of the earliest studies of ethnicity and pathways to care,
Rwegellera (1980) suggested
that low proportions of general practitioner referral and high proportions of
police referral for West Indian patients were a function of greater clinical
disturbance. The only clinical variables on which we had data that could be
considered in the analyses of referral source and ethnicity were duration of
untreated psychosis, and diagnosis. The former variable was not associated
with either general practitioner or criminal justice agency referral;
diagnosis was associated with both outcomes. However, whereas multivariable
analyses showed that a diagnosis of manic psychosis, in particular, was
independently associated with decreased odds of general practitioner referral
and increased odds of criminal justice referral, diagnosis did not fully
account for ethnic differences in source of referral. It remains possible that
other important clinical factors not measured for our study might explain, at
least partly, the ethnic differences in source of referral.

Social context and the role of significant others

The social context within which a psychotic illness develops is likely to
have an important bearing on how it is interpreted and managed. Significant
others within an individual’s social network have been shown to have a
major role in shaping how, when and what type of help is sought. Psychosis is
often other-defined, in that the resulting disturbance is first considered
abnormal or unusual by people close to the individual with the disorder, and
it is these others who often initiate help-seeking. This is borne out in our
findings, which show that only around 30% of patients initiated help-seeking
themselves. It is no surprise that those who seek help themselves are more
likely to access care through their general practitioner and to do so
voluntarily. Where this does not happen, family and friends can have a key
role in facilitating access, again as borne out in the data. After controlling
for other factors, family involvement in the pathway to care remained strongly
associated with general practitioner referral and absence of criminal justice
referral. Again, however, self-initiated help-seeking and/or family
involvement did not fully account for the ethnic differences in source of
referral, but adjusting for these and other variables did lead to a weakening
of the associations between ethnicity and path of referral.

The potential role of significant others in easing the pathway to care may
also underpin and help to explain the association between living alone or
being unemployed and source of referral. Those who live alone and/or are
unemployed may, for example, have more restricted social networks. That said,
once again the variables used to approximate different social circumstances
did not fully account for all the ethnic differences in pathways to care
observed. Both African–Caribbean and Black African patients, for
example, remained significantly less likely to access care through a general
practitioner after adjusting for, among other factors, living alone and family
involvement. One possible explanation for this is that the variables used were
too crude to fully capture patients’ social support networks, an issue
to be addressed in future research.

A further intriguing finding from this study is the observation that more
African–Caribbean family and friends initially sought help directly from
the police than did other ethnic groups. Similar findings were reported by
Owens et al (1991).
Harrison et al (1989)
argued that a tendency to heavily stigmatise mental illness in the
African–Caribbean community might act as a barrier to help-seeking until
crises develop, at which point the risk of police involvement and formal
intervention were substantially increased. There are some indications that
African–Caribbean communities do stigmatise mental illness more heavily
(Wolff et al,
1996a,b).
This could result in African–Caribbean families interpreting early
symptoms and behavioural disturbance in legal rather than medical terms,
leading them to call on the police more often as a first resort. Such
possibilities certainly merit further research.

Limitations and future research

Although this study has a number of advantages over previous research,
there remain a number of limitations. It was not possible to interview all
patients and their relatives, which meant that more data were missing relating
to information not readily elicited from case notes, for example family
involvement. We also faced a problem that has been encountered in the past in
measuring level of disturbance at presentation to services. This means that it
is still not known with any certainty whether there are differences in how
patients from different ethnic groups present to services. Further, although
data relating to living circumstances, relationship status and employment
provide crude proxies for social networks, they remain just that –
proxies. Consequently, the data can only hint at the potential role of social
contexts and networks in influencing the pathway to care.

Future research has to take account of such limitations. Indeed, the task
of future research is to understand these processes more fully as a basis for
clear proposals for reforms to make services more accessible and acceptable to
ethnic minority patients. In this much can be learnt from sociological and
anthropological approaches to the study of illness behaviour, in which the
role of significant others and the importance of culturally shaped
understandings of mental illness in shaping help-seeking have been extensively
studied (Morgan et al,
2004). It is only then that we will overcome what Harrison termed ‘
a sea of ignorance’ (Harrison,
2002: p. 199) and develop workable proposals for reform that will
break the cycle of negative experiences, coercion, disengagement and relapse
that often characterises Black patients’ experience of mental health
care in the UK.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

African–Caribbean and Black African patients are less likely to
access care through a general practitioner and more likely to access care
through a criminal justice agency at first presentation.

The involvement of significant others within a patient’s social
network in the pathway to care increases the likelihood that referral will be
by a general practitioner and reduces the likelihood that referral will be by
a criminal justice agency.

Ethnic variations in pathways to care are not fully explained by
differences in diagnosis, social circumstances and the involvement of
others.

LIMITATIONS

Limitations include the use of case notes, lack of direct measures of
clinical variables and the small size of the African–Caribbean patient
sample in Nottingham.

The reliance on case notes for a proportion of the sample meant that data
on family involvement in the pathway to care were not available for all
patients.

The indicators of social circumstances and family involvement used were
limited proxies that can only hint at the potential role of significant others
in shaping the pathway to care in different ethnic groups.

Acknowledgments

We are grateful to mental health services and patients in Bristol,
Nottingham and south-east London for their cooperation and support with this
study, and to the UK Medical Research Council and the Stanley Medical Research
Institute for funding. We are also grateful to Morven Leese for statistical
advice.